Background: Venous thromboembolism (VTE) is a serious complication following severe TBI, however, anticoagulant prophylaxis is often withheld over concerns of intracranial hemorrhage (ICH) progression. We analyzed practice patterns and outcomes among severe TBI patients and systematically reviewed the literature for studies of anticoagulant prophylaxis after severe TBI. Methods: We prospectively screened consecutive patients with severe TBI (highest GCS≤8 from time of injury to ICU admission) admitted to a Level-I trauma centre between Oct 1,2015–Sept 30,2016 to assess type/timing of anticoagulant prophylaxis, rates of new VTE and ICH progression. Results: We identified 64 eligible patients with severe TBI. Most (53;83%) received anticoagulant prophylaxis, initiated ≥3d after TBI in 67%. Ten (16%) developed VTE during hospitalization; 8 started prophylaxis prior to VTE. No significant difference was observed in VTE incidence or ICH progression between patients with early prophylaxis (<3d) vs.later (≥3d). Our systematic review identified 5 studies of heterogeneous quality/design, with reported VTE incidence of 11-30% in patients without anticoagulant prophylaxis and 5-10% in patients with prophylaxis. Conclusions: VTE is a common complication after severe TBI despite routine use of anticoagulant prophylaxis. Anticoagulant prophylaxis is often started late (≥3d) post-injury. The relative benefits of early prophylaxis versus possible risks of ICH progression should be directly compared in an appropriately powered RCT.

Background: Glioblastoma is the most common adult malignant glioma, with poor prognosis and adverse neurological sequelae. Physical activity improves outcomes in patients with other cancers, but has not been evaluated in GBM. This prospective, single-arm intervention trial examines feasibility and preliminary efficacy of exercise on PFS, cognition and QOL in newly diagnosed GBM patients. Method: Participants are English-speaking GBM patients scheduled for concurrent chemoradiation at PMH, 18-65 years old, ECOG ≤ 2. The 3-month home-based exercise program includes aerobic and resistance training, tailored to prior fitness level, current physical status, and individual interests. Assessments of physical and neurocognitive functions, mood, fatigue, sleep, and QOL, occur within 2 weeks of starting chemoradiation, and approximately 3, 6, 12, and 18 months later, or until tumor progression. Feasibility will be assessed by accrual, retention, and adherence rates. Outcomes include PFS (RANO criteria), change in cognition (reliable change index method), physical activity and sleep (actigraphy, self-report questionnaires). Time-to-event outcomes will be estimated (Kaplan-Meier), and mixed modelling will explore individual and disease variables that contribute to outcomes. Results: During the first five months of recruitment, 13 of 19 eligible patients consented. Nine completed the exercise program. One patient died after the intervention and none of the others progressed. No exercise-related serious adverse events occurred. Preliminary results will be presented at the meeting. Discussion: Exercise appears feasible for GBM patients. Effects on survival, performance status, cognition, sleep, mood, and QOL are ongoing. Results may guide physical activity recommendations in GBM and generate avenues for translational research.

Background: After correlating in vivo macrostimulation-induced pain or temperature sensation during percutaneous cervical cordotomy with simultaneous CT imaging of the electrode tip location, we present a modern description of the somatotopy of the human cervical spinothalamic tract Methods: Twenty patients with medically refractory, unilateral, nociceptive pain due to malignancy received contralateral cervical percutaneous cordotomy. In a post-hoc analysis of the data, each individual’s cervical spinal cord was measured from the CT image using PACS software. The location of the electrode tip during each stimulation-induced response was then superimposed on a diagram of their cord Results: The lower limb responses were found more superficial and posterior to those of the upper limb. Interestingly, the region for upper limb responses surrounded that for lower limb primarily anteriorly and medially (deep) but also posteriorly Conclusions: This work simultaneously combined awake physiologic localization of fibers within the human -spinothalamic tract (STT) with neuroimaging documenting their precise anatomical localization within the spinal cord. The resultant map of the STT demonstrates, for the first time, that fibers from the lower limb are located superficially and posteriorly within the anterolateral spinal cord with the fibers from the upper limb surrounding them primarily deep and anteriorly but also posteriorly

Atypical Teratoid Rhabdoid Tumors (AT/RTs) often affect children under the age of 3 and are the most common malignant CNS tumors in children younger than 6 months. It is very rare to see these tumors in patients older than 6 years of age. We discuss the case of a 14 year old male with AT/RT of the right insula. He had a prior diagnosis of Dysembryoplastic Neuroectodermal Tumor (DNET) at the age of 10, after two years of intermittent headaches, nausea, and seizures, which was treated with conformal radiation and chemotherapy for a year. Following the diagnosis of AT/RT, he underwent radiotherapy, multiple lines of chemotherapy, and two additional debulking surgeries of the left temporal lobe due to continuing progression. He was then treated with Alisertib (an Aurora-A kinase inhibitor) with good response on sequential MRIs after the first three cycles. He progressed after nine cycles of Alisertib and required further debulking surgery. Six years after his AT/RT diagnosis (and 10 years after his DNET diagnosis), the patient expired at the age of 20 due to ongoing progression. To our knowledge, this is only the second reported case of Alisertib use in a non-pediatric AT/RT case. We also performed a literature review of all reported cases of AT/RT in adults between the years 2000 – 2017 and discuss treatment options, patient demographics, and survival.

BACKGROUND: The use of high-dose chemotherapy (HDC) and autologous hematopoietic stem cell transplant (HSCT) has been used in certain pediatric patients with brain tumours to delay/spare radiotherapy. We aimed to study factors predicting a successful stem cell collection (SCC) and correlate stem cell dose infused with HSCT outcomes. METHODS: A retrospective chart review was undertaken for pediatric patients with brain tumours treated at our centre with HDC/HSCT between 2004-2016. RESULTS: Fifty-five patients were identified (32 male) with median age of 6.3 years at time of SCC (range 0.4-18.7). Patients' diagnoses were medulloblastoma (62%), ATRT (20%), and PNET (18%). Most patients (82%) underwent a single/1-day SCC, while the remaining required 2 SCC procedures. Peripheral blood stem cells were the source in most collections (95%). Successful SCC (CD34 collected greater-than-or-equal-to 2 x10^6/kg/transplant) and ideal SCC (greater-than-or-equal-to 5 x10^6/kg/transplant) was achieved in 85% and 45% of patients, respectively. Use of mobilizing chemotherapy with G-CSF was the only factor associated with achieving an ideal collection, while gender, age, stem cell source, and pre-apheresis peripheral blood CD34 count were not significant. Higher CD34/kg infused was associated with faster neutrophil engraftment in the first 3 courses of HDC/HSCT and platelet engraftment in the first course. CONCLUSIONS: The majority of SCC for autologous HSCT can be successfully completed with a single apheresis session. Mobilization with both chemotherapy and G-CSF yields higher CD34 compared to G-CSF alone. Higher dose of CD34/kg infused was associated with faster neutrophil and to a more limited scale platelet recovery post-HSCT.

Background: The effectiveness of the Hydrocephalus Research Network (HCRN) shunt protocol has not been validated in a non-HCRN, small-to-medium volume pediatric neurosurgery center. This study evaluates whether the 9-step Calgary Shunt Protocol (CSP) adapted from the HCRN shunt protocol reduced shunt infections. Methods: The CSP was prospectively applied at Alberta Children’s Hospital from May 23rd, 2013 to all children undergoing any shunt procedure. Children undergoing shunt surgery before CSP implementation acted as a control-cohort. The strict HCRN definition of shunt infection was applied. Results: A total of 268 shunt procedures were performed. There was a significant absolute risk reduction of 10.0% ([95%CI 3.9%-15.9%], p=0.004) in shunt infections after implementation of the CSP. In univariate analyses, chlorhexidine compared to povidone skin prep reduced shunt infection by 8.2% ([95%CI 1.84-14.6%], p=0.02) and waiting ≥ 20 min between receiving preoperative antibiotics and skin incision reduced shunt infections by 9.6% ([95%CI 2.4%-16.9%], p=0.02). In multivariate analysis, only protocol implementation independently reduced shunt infections (OR 0.19 [95%CI 0.06-0.67], p=0.004). Conclusions: This study externally validates the published HCRN protocol for reducing shunt infection in an independent, non-HCRN, and small-to-medium volume neurosurgery setting. Chlorhexidine skin prep and waiting ≥ 20 min between preoperative antibiotic and skin incision may have contributed to the protocol’s quality improvement success.